Written evidence submitted by Doctors of the World, the Helen Bamber Foundation, Forrest Medico-Legal Services and Freedom from Torture (COR0206)
- This briefing constitutes a joint statement by Doctors of the World (DOTW), the Helen Bamber Foundation (HBF), Forrest Medico-Legal Services (FMLS) and Freedom from Torture (FfT) of our clinical concerns relating to the use of barracks as housing for asylum seekers in the UK.
- Since the sites opened in September 2020, clinicians from DOTW, HBF and FMLS have been undertaking remote medical screening assessments of people housed in the Napier and Penally sites. These assessments have taken place at the request of legal representatives and those supporting residents or following self-referral from residents themselves. These assessments form the basis of the evidence and conclusions within this briefing, with case studies to illustrate specific points.
- In September 2020 the Home Office established full board accommodation for asylum seekers at two former Ministry of Defence sites at Penally training camp in Pembrokeshire, Wales and at Napier Barracks in Kent, England (‘the barracks’). The barracks are said to have been acquired in order to expand the provision of ‘contingency’ accommodation to meet the increased need for asylum housing during COVID-19.
- While recognising the need for an urgent response to the crisis in asylum accommodation, the decision to use this form of housing significantly diverges from the community dispersal model which has been a core feature of the provision and planning of asylum accommodation to date. People were moved into the barracks rapidly, with little warning given to local authorities or communities, and before appropriate healthcare systems, pathways and facilities were fully in place.
- In our expert clinical view, the barracks have caused and continue to cause severe harm to residents. Given the deteriorating conditions in the Napier site (including mental health crises, the aftermath of the fire and arrests, locking COVID-19 positive residents in alongside other residents and without proper clinical care) there is a critical need to evacuate the barracks immediately, where in our view conditions breach Article 3 ECHR.
The barracks are harmful to health and well-being
- People seeking asylum and who have fled persecution are an inherently more vulnerable population, because of their experiences of war, conflict, torture, human trafficking, and other forms of abuse. As a result of their experiences they face significant healthcare challenges and have a high prevalence of trauma symptoms (which can meet diagnostic thresholds for post-traumatic stress disorder [PTSD] and/or for anxiety and depressive disorders).
- DOTW’s clinical consultations with residents of the Napier site demonstrate that the general wellbeing of those accommodated has been profoundly harmed by the experience. Many residents cannot sleep because of the noise generated by more than 20 people in the same room. Some reported they cannot eat due to poor appetite, that the food is not fresh or is undercooked, and they have lost weight.
- During DOTW’s assessments of people housed at the Napier site, the majority of people reported that they had felt down, depressed or hopeless nearly every day over the previous two weeks, and the majority reported they had little interest or pleasure in doing things nearly every day over the last two weeks. Many people reported trauma from past experiences and DOTW doctors identified several residents with PTSD, as well as many others with poor mental health including depression, anxiety and suicidal ideation. Several have reported suffering from flashbacks and nightmares. There is also a constant feeling of uncertainty of what is going to happen next which further exacerbates these conditions.
- Many reported that the accommodation reminded them of their past experiences of exploitation and abuse including experiences of illegal imprisonment, and other negative experiences including violence. One person stated that: “we’re being housed like goats” and another stated: “this is the same as when we were imprisoned in Libya, just without the physical violence”.
- PTSD is often linked with symptoms of irritability, nightmares, intrusive thoughts, flashbacks, and hypervigilance which can be aggravated by the shared facilities used in the barracks. Prior to the introduction of the barracks sites, our patients in shared accommodation frequently reported that the presence of others in the room at night contributes to sleeplessness and risks escalating tensions and conflict. This has been echoed in our assessments of those at the barracks.
- The isolation from communities, placement in a male-only facility with large dormitories, very limited, or no perceived, privacy and substantially reduced access to community spaces and services all amplify the residents’ sense of being isolated, discriminated against, and/or punished. Poorer mental health is also associated with asylum seekers living in institutional accommodation even without the connotations and privations of being in an isolated ex-military facility.
The barracks are COVID-19 insecure and a risk to public health
- Our evidence suggests that the barracks are not COVID-19-compliant and we believe this is unacceptable during a global pandemic and in light of public health guidelines to limit contact in order to reduce transmission.
- People have been transferred into the sites from numerous different local authority areas, some of which have experienced very high incidences of COVID-19, and they are then kept together in close proximity with shared facilities (most notably lavatories and bathrooms) that make social distancing and good hygiene practices impossible.
- It is our understanding from residents that self-isolation on arrival was not facilitated after they were moved to the camp from other areas of the UK. Indeed, there are no, or no adequate, facilities on site for residents to self-isolate should they develop symptoms of COVID-19 or test positive, as demonstrated in our experience in one case of suspected tuberculosis.
- From a public health perspective this creates an unacceptable risk of infection for residents, non-residents in the community, staff, emergency services and clinical personnel.
- It has been established and documented that BAME people in the UK are at heightened risk of infection and death from COVID-19. Furthermore, at the time of writing viral variants are spreading in the UK and the ‘r’ number and UK death rate will, it would seem, remain high for some time notwithstanding efforts to counter this.
- There has been a major outbreak of COVID-19 amongst residents at the Napier site. As at 25th January 2021, 120 of the 390 residents tested positive for COVID-19. Those with positive and negative results, symptomatic or not, continued to share the same spaces and the same facilities. The residents have now been put into quarantine, and people are not allowed to leave the site. Some of the residents have since been re-located off-site to other accommodation allowing them to self-isolate appropriately, but we continue to hear reports from those remaining on the site, of COVID -19 positive residents housed in dormitories with those who have received a negative test result. Those remaining on the Napier site are terrified of the risk of contracting COVID-19 due to the lack of self-isolation space, and the shared facilities.
- The living conditions have worsened following the recent fire which impacted on facilities such as potable water, heating and electricity, with potentially serious health risks for residents including those with positive COVID-19 diagnoses. In these circumstances it is our view that the conditions have crossed the threshold of harm to inhuman and degrading treatment, particularly given the psychological distress caused by residents being contained together during a COVID-19 outbreak.
- This situation was entirely foreseeable and should have been prevented. We wrote to the Home Secretary and the Secretary of State for Health and Social Care on 26th November 2020 warning of the risk of a COVID-19 outbreak at the barracks. Instead of evacuating before or at the first sign of the outbreak, residents were trapped on the site and exposed to an unacceptably high risk of infection. We understand that reported resultant levels of distress have been exceptionally severe.
- This outbreak represents a public health risk to the whole population and the continued use of barracks is undermining the efforts and sacrifices made by the British public to stop the spread of COVID-19.
There is not adequate access to healthcare
- We understand that NHS trusts who have clinical responsibility for residents at Penally and Napier were given only approximately two days’ notice before the sites opened and the residents were moved in. It is both unsafe and unethical for healthcare pathways not to have been developed before people were moved into the sites.
- DOTW’s medical assessments with people housed in Napier barracks show that people do not have ongoing access to a GP, and that they only have access to a nurse or occasionally a doctor on site. One clinician cannot possibly adequately address the health needs of a population of approximately 390 people. In the assessments conducted by DOTW, all the people consulted had complex health and wellbeing needs. In the application of Patient Health Questionnaire (PHQ-9), no one reported that they have a ‘good’ or ‘very good’ general health, with most people reporting they have ‘very bad’ or ‘bad’ health. DOTW GPs recorded physical and mental health conditions (PTSD and anxiety, sleep disturbance and other mental health issues; headaches, migraine, dysuria, rash, back pain) which could be treated with a meaningful and easy access to GP and secondary care referral pathways. However, we understand that seven people who attempted to access Kent Mental Health Single Point of Access team have been declined.
- Even though the sites have been open for several months, healthcare pathways remain inadequate. Residents at the Penally site generally have to go through a member of the contractor’s staff (Clearsprings Ready Homes) in order to access an NHS medical appointment. The use of such untrained personnel as gatekeepers and, effectively, as de facto GP receptionist is a breach of the residents’ right to confidentiality. We understand that residents have been required to share their medical information (some of which is necessarily intimate) with an untrained third party and, without interpreter support.
- An HBF GP assessed a torture survivor suffering urinary incontinence who had to disclose private medical information to Clearsprings Ready Homes staff. The patient reported that he found this humiliating and his mental health trauma symptoms were objectively worsened thereby. The same HBF GP assessed another survivor of abuse who had suffered a severe one-sided headache for several days and whom she identified as in need of urgent medical assessment, but camp staff had wrongly triaged his presentation as ‘non-serious’.
By failing to protect the most vulnerable, all residents are at risk
- The barracks are clearly inappropriate for particularly vulnerable people including survivors of torture and those who have been subjected to human trafficking or enslavement. People who have experienced such trauma are unlikely to regard an ex-military camp as a place of safety given that, as DOTW evidence shows, it is likely to be a reminder of their previous experiences. Such an environment is highly likely to trigger a trauma response, and potentially retraumatisation, and lead to the deterioration of mental health and well-being.
- The Home Office recognises that some limited categories of people should not be accommodated in the barracks and claims to be ‘screening’ to ensure that ‘the most vulnerable’ are not sent to Penally and Napier. However there is no specific vulnerability assessment questionnaire and the process appears to be no more than a desk-based review of the evidence that happens to already exist on file. Such a review is unlikely to provide sufficient information to identify vulnerability, particularly for those whose asylum claim has not been substantively considered (which is the case for all of those in the barracks) because details of history will be very limited prior to their substantive asylum interview. We are aware that some particularly vulnerable persons have been moved out of Penally having been recognised as such on FMLS or HBF clinical assessments, but others, who have also been so assessed still remain in Penally.
- Our findings suggest that the Home Office ‘screening processes’, such as they are, are not working. Fundamentally and in our collective professional experience over decades of clinical work in this area, it will simply not be possible for the Home Office to identify hundreds of people seeking asylum who could safely live in conditions like the barracks when refugee populations are an inherently vulnerable group suffering a high prevalence of trauma.
- As a result of the failure to screen effectively, our clinicians have identified many vulnerable people who have inappropriately been placed in the barracks. In October 2020, an HBF GP independently assessed an asylum seeker placed in the Penally site who clearly stated in his asylum screening interview that he had injuries due to torture and who reported trauma symptoms. Having assessed the patient the GP found that the placement in the camp was harmful to his health and well-being.
- As time as gone on and the conditions of the sites have taken their toll there have been increasing reports of suicidality and mental distress. In the absence of a functioning screening process or adequate safeguards to identify and respond to vulnerability, and in recognition of the high rate of trauma amongst this population, it is our belief that the barracks are potentially harmful for the health and wellbeing of all those accommodated on the sites.
Use of the barracks breaches the Home Office public sector equality duty
- The creation of the sites failed to take the legally required anticipatory approach to disability as a protected characteristic. Given the prevalence and seriousness of mental health issues amongst asylum seekers and victims of modern slavery, it is not good enough to take a purely reactive approach, i.e., responding only once medical evidence of vulnerability and harm has been provided. Conditions that are frequently seen among these populations often amount to a disability, such as physical injuries due to torture, post-traumatic stress disorder, depression and anxiety, and these conditions should be anticipated and information from specialist bodies obtained to inform appropriate decision making and onward treatment and care.
- Shared facilities in asylum seeking accommodation can also create enhanced risks of harassment for LGBTQ+ asylum seekers which can have a damaging impact on their health and well-being and can result in homelessness and potentially in exploitation. Within the dormitories in the barracks, with comparatively limited staffing presence, there are particular risks of social stigma, discrimination, harassment, and hate crime to people who are perceived as being LGBTQ+, who are perceived as expressing gender diversity, or who are LGBTQ+ and speak about this openly or are involved in same sex relationships. For LGBTQ+ people in particular, the shared accommodation in the barracks is inherently unsuitable.
- We are not aware of any support or processes in place for LGBT+ residents, or others with protected characteristics who may be perceived as not ‘fitting in’ such as religious converts, to be identified and safeguarded, to access specialist support, and to share and communicate concerns as they would be able to do in mainstream community settings.
33. About the Authors
Doctors of the World
- Doctors of the World (DOTW) UK is part of the Médecins du Monde international network, an independent humanitarian movement. DOTW has been a registered charity in England and Wales since 1998 and runs clinics and advocacy programmes providing medical care, information, and practical support to people unable to access NHS services. Our patients include refugees, asylum seekers, survivors of human trafficking, people experiencing homelessness, sex workers, migrants with insecure immigration status and Gypsy, Roma, and Traveller communities. For this evidence submission DOTW conducted 15 medical assessments from Napier barracks.
Helen Bamber Foundation
- The Helen Bamber Foundation is an expert clinical and human rights charity. Our multidisciplinary and clinical team works with survivors of human trafficking/modern slavery, torture, and other forms of extreme human cruelty. We provide a bespoke Model of Integrated Care for survivors which includes medico-legal documentation of physical and psychological injuries, specialist programmes of therapeutic care, a medical advisory service, a counter-trafficking programme, housing and welfare advice, legal protection advice and community integration activities and services.
Forrest Medico-Legal Services (FMLS)
- FMLS is a Community Interest Company operating on a not-for profit basis. Its members and associate members are experts in the field of the assessment and documentation of clinical evidence of human rights abuses. This remit includes consideration of issues such as the lack of access to necessary care. FMLS experts have (as at the date of preparing this submission) examined 15 residents of Penally and two former residents shortly after their departure.
Freedom from Torture (FfT)
- Freedom from Torture is a UK-based human rights organisation and one of the largest torture rehabilitation centres in the world. Each year we provide clinical services to more than 1,000 survivors of torture in the UK, the vast majority of whom are asylum seekers or refugees. We provide medico-legal documentation and have a Legal Advice and Welfare Service that provides support to torture survivors in treatment at a Freedom from Torture centre. The experiences of people who have survived torture drive and inform everything we do.
 Porter and Haslam (2005), JAMA Aug 3;294(5):602-12. ‘Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis’; and MSS v Belgium and Greece available at: https://www.asylumlawdatabase.eu/en/content/ecthr-rahimi-v-greece-application-no-868708-1
 This is a finding revealed as a result of our consistent application of Patient Health Questionnaire (PHQ-9) which is used to monitor severity of depression.
 Ibid. at 3.
 For example the Hywel Dda University Health Board in Penally recorded high risks from COVID-19: https://hduhb.nhs.wales/about-us/governance-arrangements/statutory-committees/quality-safety-and-experience-assurance-committee-qseac/qseac/extraordinary-quality-safety-and-experience-assurance-committee-meeting-13-november-2020/item-2-3-health-response-to-the-use-of-the-mod-tra/
 Page 3 ‘Contingency asylum accommodation, Ministry of Defence sites Factsheet’, October 2020.
 Even applying the Home Office’s own restrictive definition of vulnerability, as in their internal policy ‘Suitability assessment for contingency accommodation, v.6’.
 See for example ‘Asylum seeker ‘tried to take own life’ in ex-military base where hundreds are being held’ 19 November 2020, Bulman, The Independent.
 See for example 3.5.2 ‘Over not out’, Refugee Support (2009). See also ‘No safe refuge: experiences of LGBT asylum seekers in detention’, UKLGIG and Stonewall (2016).